Evaluation and management of spontaneous Intracerebral hemorrhage
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Spontaneous intracerebral hematoma (ICH) is a severe form of stroke with a mortality rate of 30% to 40%, influenced by factors such as hypertension, age, and anticoagulant use. Management includes rapid assessment, blood pressure control, and potential surgical intervention, particularly for larger hematomas or when neurological deterioration occurs. Recent studies highlight challenges in surgical trials, including recruitment issues and the complexity of patient selection.
![Spontaneous Intracerebral Hematoma
Dhaval Shukla
Prof. & HOD of Neurosurgery
National Institute of Mental Health and Neurosciences
[NIMHANS] Bangalore](https://image.slidesharecdn.com/ich-copy-240311011558-046e54d4/85/Evaluation-and-management-of-spontaneous-Intracerebral-hemorrhage-1-320.jpg)
Evaluation and management of spontaneous Intracerebral hemorrhage
- 1. Spontaneous Intracerebral Hematoma Dhaval Shukla Prof. & HOD of Neurosurgery National Institute of Mental Health and Neurosciences [NIMHANS] Bangalore
- 2. Epidemiology of Stroke • Annual incidence 108/100,000 to 172/100,000 • Hemorrhagic – 11% in Trivandrum to 35% in Kolkata • Hypertension • Higher salt intakes • Females 41% • One-month case fatality 18% to 42% – Highest in the studies based in Kolkata (41–42%) Int J Stroke 2022
- 3. ICH • Deadliest form of acute stroke • Mortality about 30% to 40% • No or minimal trend toward improvement – Incidence of ICH increases sharply with age – More widespread use of anticoagulants
- 5. ICH - Locations Arteriosclerosis Cerebral Amyloid Angiopathy
- 6. ICH - Risk Factors Arteriosclerosis Risk factors • Hypertension • Diabetes • Age Cerebral Amyloid Angiopathy Risk factors • Age • Apolipoprotein E genotypes containing the ε2 or ε4 alleles
- 12. Angiogram • <70 years of age with lobar ICH • <45 years of age with deep or posterior fossa ICH • 45 to 70 years of age with deep or posterior fossa ICH and the absence of both hypertension and signs of small vessel disease on imaging • All patients with ICH with CT or MRI evidence of a macrovascular lesion • Patients with primary IVH
- 14. Courtsey – Dr. Nadeem, NIMHANS
- 18. ICH – Different Etiology Anticoagulant Arteriovenous Malformation
- 19. Pathophysiology
- 20. Hematoma Volume Expansion > 30 ml unfavorable outcome > 60 ml & GCS < 8 Mortality > 90% > 150 mL immediate death
- 21. Hematoma Expansion (HE) Predictors and Risk Factors • CT scan – Timing – NCCT – CTA • Hypertension • Anticoagulants
- 22. HE – CT timing ICH • 15% - 6 and 12 hours • 6% - 12 and 24 hours • 0% - 24 hours IVH • 21% - >24 hours Cerebral Oedema • 48 hours 4 CT scans Initial < 3 hours • 6 hours • 24 hours • 48 hours
- 23. Noncontrast computed tomography (NCCT) markers of risk of HE
- 24. Computed tomography angiography (CTA) spot sign marker of risk of HE 2 hours of onset of symptoms
- 25. Hypertension • Initiate treatment within 2 hours of ICH • Target SBP 130 to 150 mm Hg • Careful titration • Continuous smooth and sustained control • Avoid peaks and large variability • SBP to <130 mm Hg is potentially harmful
- 27. HE - General Hemostatic Treatments • Platelet transfusion – Only for patients scheduled for surgery – Harmful otherwise • No role of following – Desmopressin – Factor VIIa – Tranexamic acid
- 28. Issues in Medical Management
- 29. Issues in Medical Management
- 30. Issues in Medical Management
- 31. Monitoring
- 33. RCT -MIND
- 34. RCT - ENRICH
- 35. MIS • ICH of >20- to 30-mL • GCS 5–12 – Reduce mortality – Functional outcomes is uncertain • Select MIS over craniotomy to improve functional outcomes >80% reduction of ICH volume is required Only 1/3rd patients achieve this target
- 37. Craniotomy & Evacuation of ICH • Moderate or greater severity – Functional outcomes or mortality is uncertain • Deteriorating – Lifesaving
- 38. Decompressive Craniectomy (DC) Indications • Coma • Large hematomas • Significant midline shift • Elevated ICP refractory to medical management DC with or without hematoma evacuation may be considered to reduce mortality Functional outcomes is uncertain
- 40. Surgery is an Option Younger
- 41. Supratentorial ICH without significant IVH
- 43. Minicraniotomy Courtsey – Dr. Akshohini Garg, NIMHANS
- 45. Why surgical ICH trials may have failed? • The primary injury of hemorrhage is not possible to be treated with surgery. • Neurosurgical patients requiring urgent procedures are difficult to recruit. • The ideal candidate and the optimal timing of surgery are essential questions that have not been determined. • Many clinicians would consider hematoma drainage a life-saving measure in some situations; therefore, patients who were considered to benefit from surgery were not enrolled in these studies.
- 46. Why surgical ICH trials may have failed? • Large crossover from medical management to surgical group. If no patient had crossed over from medical management to surgical group, the rates of unfavorable outcome and death with conservative management would have been higher. • Problems with study designed, sample size, and number of excluded patients. • Slow recruitment due to very restrictive inclusion protocols. – A population-based study showed that very small percentages of ICH patients were eligible for the STICH II trial, i.e., 9.5% of lobar ICH without IVH and only 3.7% of all ICH patients
- 47. Cerebellar hematomas • Deteriorating neurologically • Brainstem compression and/or hydrocephalus • Volume ≥15 ml Immediate surgical removal of ICH with or without EVD is recommended to reduce mortality
- 49. Out of sight out of mind
- 50. Out of sight out of mind
- 51. Outcome Prediction Neurological Research and Practice 2021
- 52. Recurrent ICH • Arteriosclerosis – 1.1%/ year • CAA - 7.4% year – lobar location – older age – presence, number, and lobar location of microbleeds – presence of disseminated cortical superficial siderosis – poorly controlled hypertension 130/80 mm Hg – presence of apolipoprotein – E ε2 or ε4 alleles
- 55. Take Home Message • ICH is deadly • In the patient with suspected stroke – Perform a rapid assessment – Obtain a glucose and noncontrast head CT – CTA may be helpful, as can venography in select patients
- 56. Take Home Message • Once ICH is diagnosed on CT, goals are to – stabilize the patient, – control BP (rapid control with an IV infusion), – prevent further injury (avoid elevated ICP, hypoxia, hypotension, hypoglycemia), – admit to an appropriate facility Do surgery immediately for IVH and Cerebellar Hematoma
- 57. Further Reading
Editor's Notes
- #2: Clinical Update - 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage (heart.org)
- #3: Stroke in India: A systematic review of the incidence, prevalence, and case fatality - Stephanie P Jones, Kamran Baqai, Andrew Clegg, Rachel Georgiou, Cath Harris, Emma-Joy Holland, Yogeshwar Kalkonde, Catherine E Lightbody, Pallab K Maulik, Padma MV Srivastava, Jeyaraj D Pandian, Patel Kulsum, PN Sylaja, Caroline L Watkins, Maree L Hackett, 2022 (sagepub.com)
- #4: ICH is arguably the deadliest form of acute stroke, with early-term mortality about 30% to 40% and no or minimal trend toward improvement over more recent time epochs.6ncidence of ICH increases sharply with age and is therefore expected to remain substantial as the population ages, even with counterbalancing public health improvements in blood pressure (BP) control.8 Another growing source of ICH is more widespread use of anticoagulants,10 a trend likely to counterbalance the reduced ICH risk associated with increasing prescription of direct oral anticoagulants (DOACs) relative to vitamin K antagonists (VKAs)
- #6: https://pubs.rsna.org/doi/abs/10.1148/radiol.2018170803?journalCode=radiology
- #7: https://pubs.rsna.org/doi/abs/10.1148/radiol.2018170803?journalCode=radiology
- #11: https://www.ahajournals.org/doi/10.1161/STROKEAHA.113.003701#F1
- #14: Siddappa 20170056480
- #17: https://insightsimaging.springeropen.com/articles/10.1186/s13244-022-01309-1
- #18: https://pbrainmd.files.wordpress.com/2023/02/image-8.png https://radiopaedia.org/cases/evolution-of-ct-density-of-intracranial-haemorrhage-diagram
- #20: de Oliveira Manoel AL. Surgery for spontaneous intracerebral hemorrhage. Crit Care. 2020 Feb 7;24(1):45. doi: 10.1186/s13054-020-2749-2. PMID: 32033578; PMCID: PMC7006102.
- #21: https://radiopaedia.org/articles/abc2
- #22: https://radiopaedia.org/articles/abc2
- #23: https://radiopaedia.org/articles/abc2
- #24: Figure S1. Examples of reported noncontrast computed tomography (NCCT) markers of risk of hemorrhage expansion. Axial slices of acute noncontrast CTs in intracerebral hemorrhage (ICH) Figure S1. Examples of reported noncontrast computed tomography (NCCT) markers of risk of hemorrhage expansion. Axial slices of acute noncontrast CTs in intracerebral hemorrhage (ICH)
- #25: spot sign marker of risk of hemorrhage expansion. Axial slices of computed tomography angiography (CTA) A, NCCT demonstrates a right thalamic ICH (24 mL) with associated IVH (6 mL). B, Axial CTA source image in spot windows demonstrates 3 foci of contrast pooling within the ICH with an attenuation ≥120 HU (arrowheads), consistent with spot signs (a total of 5 spot signs were identified). The largest spot sign measures 10 mm in maximum axial dimension and has an attenuation of 225 HU (spot sign score, 4). C, Delayed CTA acquisition 48 seconds after the first-pass CTA shows that the spot signs increased in volume and changed in morphology (arrowheads). D, NCCT 8 hours after the baseline CTA demonstrates marked interval expansion of both the ICH (94 mL) and IVH (82 mL)
- #34: https://journals.lww.com/onsonline/fulltext/2020/06000/a_compendium_of_modern_minimally_invasive.19.aspx
- #37: A case from MISTIE Ttrial
- #44: Somu 20240019482
- #46: de Oliveira Manoel Critical Care (2020) 24:45 https://doi.org/10.1186/s13054-020-2749-2
- #52: https://neurolrespract.biomedcentral.com/articles/10.1186/s42466-021-00120-5/tables/1